Making Sound Decisions in Health

In past blogs, I have frequently discussed the need for the consumer to be a more active participant in the health ecosystem. I passionately believe the citizen/consumer has to be accountable for their many personal health decisions – such as lifestyle, smoking, nutrition, activity levels and the like. It is simply not right or fair that the additional health costs of others’ lifestyle choices be a financial burden on all of us. The most recent government forecast for Medicare expenditures says on page 44:

"Total Medicare expenditures were $523 billion in 2010 and are expected to increase in most future years at a somewhat faster pace than either workers’ earnings or the economy overall. Based on the intermediate set of assumptions and current law, expenditures as a percentage of GDP are projected to increase from the current 3.6 percent to 6.2 percent by 2085."

And then the report goes on to say Part B expenditures are substantially understated in the forecast!

Let me be clear – I am NOT saying that all health costs or even that the rise in health costs are all the result of consumer lifestyle choices – they are not. But they do play a part – and if we are ever going to solve our financial crisis in the US – we need to get more value (better health outcomes at the same or lower cost) out of our huge and growing health expenditures. This will require reform across many fronts – payment reform, physician culture and importantly, consumer engagement and accountability.

So with the above context in mind, I read with interest this Forbes article by Leslie Michelson, What Steve Jobs’ Death Can Teach Us about our Own Health Care. I encourage you to read it. Michelson’s basic premise is that the approach Jobs took to making a critical health decision was flawed, and because he took nine months to try alternative options prior to surgery, surgery ended up not being enough. More importantly, Michelson’s point is that making medical treatment decisions is ‘different’ than everyday business or life decisions and that you need a framework (and support) for making them. They are different for two key reasons – one, the overwhelming emotional stress associated with them (in the case of life-threatening issues) and two, the specialized knowledge and collaboration required.

Despite the fact that I believe many other business or life decisions are high stress – I completely agree with him. Making decisions about health is different and requires a different decision framework. Personally, I have been dealing with health decisions related to a parent-in-law. The decisions (where to go, who to see, what to do next) are just hard, and the health delivery system is neither helpful – nor designed to be – in guiding patients through the decision-making process.

Michelson’s first step in the framework is to get an ‘accurate and complete diagnosis.’ Sounds right to me – but in my experience, even after many doctors, specialists, innumerable diagnostic tests and biopsies, plus a few hospital stays – we still don’t have even that. We have met many caring and thoughtful people along the journey, but we haven’t really had much help in how to think about and approach the key decisions – and nothing about how to deal with inability to diagnose.

I believe one of the big areas for innovation in health is in consumer decision making and behavioral insight. Dartmouth has long been a proponent of ‘shared decision making’ and has set up a Center for it. There clearly is a lot to learn just in the basics. However, I think the knowledge and possibilities for innovation are going to explode as the infrastructure is put in place now for an explosion of data and more closed loop feedback systems. With EMR data flowing into patient-centric data platforms like HealthVault – which are increasingly being connected to mobile devices or home health devices with masses of data points around activity, diet, pill taking, lifestyle preferences – we will be able to use ‘big data’ tools and machine learning to identify what works for which groups. It will be very exciting. As Glenn Reynolds over at Instapundit frequently says about innovations – faster, please.